[cr4ig_]

I think affluence of the local population and job competition also affect the rankings. The places with the worst-rated homes generally have larger populations of less affluent (i.e. on Medicaid or will be soon) patients, and there are also a lot of other job options for people aside from working in that sort of a facility (not the most pleasant job to be sure). The ones with the best rankings seem to be in areas where there is a more affluent population (nursing care ain't cheap) and/or jobs in a nursing care facility are more attractive compared to other local options (resulting in a higher quality workforce). A rough correlation, YMMV.

But that last bit about lack of other attractive job options contributing to a higher quality workforce was something that I was told by someone looking for nursing/assisted living care options, and in my experience (aging parents and aging parents of friends) it is actually true. I can also confirm from personal experience that New Mexico has absolutely horrible nursing/elder care.

Lastly, re: I think I'd rather kill myself than ever go live in a nursing home? You and me both. I've seen enough that I'd rather take myself out at a time/place of my choosing rather than go into nursing care. I don't think most people give it a thought though, much less have seen it firsthand.